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In March 2009 the Healthcare Commission produced a report entitled: 'Equality in later life - A national study of older people's mental health services' (Healthcare Commission, 2009). The key aim of the report is to aid future development and planning of mental health services for older people by analysing services currently in place.
The report elucidates the magnitude of a significant national problem afflicting older people by noting that (conservative) Department of Health estimates (Department of Health & CSIP, 2005) suggest that in the UK mental health problems are present in 40% of older people attending their GP, in 50% of older adult inpatients in general hospitals, and in 60% of residents in care homes. Just over 25% of admissions to mental health inpatient services involve those aged over 65. Along with an expected increase in over 65 year olds of 15% in the next 10 years will come a higher prevalence of mental health problems, particularly depression and dementia. Currently dementia care costs £17 billion per year and this figure is set to increase (Knapp et al., 2007). The need for improved mental health services specifically for older people in the UK is therefore vital.
The report reveals that inspection of the National Services Frameworks for Mental Health (1999) and for Older people (2001) revealed some of the factors that affect the delivery of mental health services for older people include substandard diagnosis of mental health problems in older people and the variable awareness of the availability of services. A report from the Commission for Health Improvement (2003) on the abuse of older people with mental health problems noted a lack of priority for mental health services for older people generally within the health community, and “confused and ineffective” implementation and monitoring of the relevant national service frameworks. Overall there is less emphasis placed on the mental health needs of older people when compared to what is available for younger people. Older people who have transferred from general adult services reported that the services for older adults was of a poorer quality, had fewer services and less support (Healthcare Commission, 2006).
The report is largely based upon screening performed at six specialist mental health trusts in England (approx 10% representation of all mental health trusts in England) and analysis of data collected from national datasets. Four 'themes of study' were described.
Theme One: Ageism & Age Discrimination
Of the six trusts screened, two provided services that were considered service-need led. Both of these trusts had identified a clear role for specialist older people's mental health skills. Examples of good practice in these trusts were greater input by social services and intensive care units with staff skilled in caring for older adults.
Out of hours and crisis services were found to be particularly poor with some trusts only allowing out of hours referrals for patients under 65 years or for conditions other than dementia. Psychological therapy referrals were also limited for over 65s, in one trust of the 1,300 referrals made by GPs to psychological therapies only 49 were for patients over 65.
Theme Two: Quality of inpatient care
Overall the report found that in most of the trusts services users felt they received sufficient support as inpatients. The use of carers or services users on interview panels to improve services was emphasised.
Factors that were noted to be of particular benefit in improving quality of care were a good physical environment and meaningful activities tailored to the patients' needs.
Importantly, the report found that the trusts that were performing to a high standard of inpatient care were those that had strong clinical and managerial leadership. The 'modern matron' was also praised for her role in promoting and maintaining high standards of care particularly in the ward setting. The BME (black and ethnic minority) workers were vital in ensuring that patients from BME communities were provided for.
Theme Three: How comprehensive are services?
The trusts that were found provide the most comprehensive service were those that had strong clinical leadership and central clinical governance structures. Services found to be particularly poorly provided for were out-of-hours/crisis services, alcohol services, liaison services and psychological therapies.
Theme Four: Working with other organisations
The area examined how specialist services worked and interacted with primary care, adult social services and acute hospitals. The main limiting factor in the provision of an integrated service was found to be the number and complexity of different organisations involved, trusts were found to be working in conjunction with several PCTs and local authorities. Another factor which impeded integration was incompatible IT systems e.g. oftentimes patients known to both geriatric and old age psychiatry services do not know when a patient is in either inpatient setting despite being on the same site!
When compared to services for younger adults, old age community mental health teams were found to be less well integrated. Data from the National Audit Office (2007) revealed that only 48% of community mental health teams considered themselves 'integrated'. This lack of integration in turn leads to a significant reduction in the level of satisfaction felt by patients and carers about the availability of services required.
Priorities for action
The report lists four 'Priorities for action'. Some of the salient recommendations from these include:
1) Improving the quality and relevance of data
Good quality data is vital in ensuring health needs are being met. The report suggests the Department of Health should develop a range of outcome measures to monitor local and national progress. The results of this report were limited by a lack of national data for comparison.
2) Whole systems working and commissioning
This is an important priority as exemplified in the National Service Framework for Older People Standard 7 which states: 'Older people who have mental health problems have access to integrated mental health services, provided by the NHS and councils to ensure effective diagnosis, treatment and support for them and for their carers'.
The Care Quality Commission should review how well current services are integrated for example by examining how well the physical needs of older people are being met, care of older people in residential homes and the process of discharge from acute hospitals. Another incentive could be provided by the Department of Health in a 'payment by results' (PBR) system to drive age equality although quite how PBR will precisely apply to and accurately reflect the multifactorial and complex nature of older people in the psychiatric setting remains to be fully explained currently.
3) Leadership
The report found a clear link between good practice and leadership at a clinical and senior level. Strong leadership ensures that older adults experience a non-discriminatory service whilst still benefiting from a specialist old age service. Commissioners and providers should work together to deliver whole system outcomes using the World Class Commissioning approach.
4) Discrimination
The report found there was clear evidence of age discrimination particularly in access to services. The Department of Health should ensure that a holistic approach is established in older age psychiatric services on a needs basis rather than age, which could be achieved by introducing an equalities impact assessment. Commissioners and providers of care should start to assess their service for discrimination now in preparation for the forthcoming Equality Bill.
New Horizons
The report concludes that the standard of older people's mental health services are falling behind those for younger people and this is perpetuated by the lack of implementation of a standard model of care. Whilst the general tone of the report was a little downbeat – “it would be wrong to give an entirely negative view of the priority given to older people’s mental health services nationally or the progress that has been made locally” – the report found many examples of excellent practice by committed workforces. It did observe however that services are still some way from delivering the mental health standard from the National Service Framework for Older People.
The ‘New Horizons’ project led by the Department of Health, is working on the successor to the existing National Service Framework for mental health, which expires in 2009. The report recommends that this project steers the strategic direction for mental health services towards including adults of all ages and tackles age discrimination in mental health services.
The report is unequivocal in that “Concerted action is required now.” It hopes the Equality Bill, the National Dementia Strategy and the new vision for mental health services provide a focus, but World Class Commissioning and strong and effective leadership producing a coordinated response at all levels of the health and social network will be required to deliver these results.
Poonam Jain and
Martin Curtice
References
- Commission for Health Improvement (2003) Investigation into matters arising from care on Rowan Ward, Manchester Mental Health & Social Care Trust.
- Department of Health and the Care Services Improvement Partnership (2005) Everybody’s Business – integrated mental health services for older adults: a service development guide.
- Healthcare Commission, Audit Commission, Commission for Social Care Inspection (2006) Living well in later life: A review of progress against the National Service Framework for Older People.
- Healthcare Commission (2009) Equality in later life – A national study of older people’s mental health services. Gateway number 169. http://www.cqc.org.uk/publications.cfm?fde_id=11810
- Knapp, M, Prince, M, Albanese, E, Banerjee, S, Dhanasiri, S, Fernandez, J L, Ferri, C, McCrone, P, (2007) Dementia UK: A report into the prevalence and cost of dementia prepared by the Personal Social Services Research Unit (PSSRU) at the London School of Economics and the Institute of Psychiatry at King’s College London, for the Alzheimer’s Society.
- National Audit Office (2007) Improving services and support for people with dementia.
BGS Newsletter, July 2009
Issue 22 ISSN 1748-6343 22 |